Blue Cross and Blue Shield of Nebraska MA Connect (PPO)
SAPPHIRE EDGE, INC. · 2027 plan year
Plan ID H8181-002-000
Local PPO★ 3 CMS Stars
- MOOP (in-network)
- $6,650
- MOOP (combined)
- $9,000
- Monthly premium
- $0/mo
- Part C $0 + Part D $0
- Prescription drugs
- Included
Plan information
- Contract / Plan / Segment
- H8181-002-000
- Medical deductible
- $0 — no deductible
- Part D premium
- $0/mo (part of the monthly premium above)
- Part D deductible
- $400/yr
- Also owed
- Your Medicare Part B premium, paid separately
More SAPPHIRE EDGE, INC. plans in NE
Benefits & cost sharing
Hospital
| Benefit | In-network |
|---|---|
| Inpatient Hospital — Acute | $550/day for days 1–5, $0 after |
| Inpatient Hospital — Additional Days (Acute) | No charge |
| Inpatient Hospital — Psychiatric | $400/day for days 1–5, $0 after |
| Worldwide Urgent Care Coverage | $130 |
Pharmacy
| Benefit | In-network |
|---|---|
| Part B Drugs | See plan details |
| Chemotherapy & Radiation Drugs (Part B) | 0%-20% coinsurance |
| Other Part B Drugs | 0%-20% coinsurance |
Mental Health
| Benefit | In-network |
|---|---|
| Mental Health Specialty Services | See plan details |
| Mental Health — Individual Sessions | $40 |
| Mental Health — Group Sessions | $40 |
| Supplemental Health Benefits | See plan details |
Other
| Benefit | In-network |
|---|---|
| Hearing — Exams | $0-$50 |
| Hearing — Exams | See plan details |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Worldwide Emergency Transportation | $130 |
| Partial Hospitalization Program | $60 |
| Skilled Nursing Facility (SNF) | $0/day for days 1–10, $10/day for days 11–20, $218/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $30 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $30 |
| Pulmonary Rehabilitation — Additional Sessions | $25 |
| Supervised Exercise Therapy (SET) | $25 |
| Emergency Services | $130 |
| Urgently Needed Services | $50 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $130 |
| Intensive Outpatient Program (IOP) | $60 |
| Home Health Services | No charge |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $15 |
| Occupational Therapy Services | $50 |
| Physician Specialist Services | $50 |
| Podiatry Services | $50 |
| Radiological Services | See plan details |
| Other Health Care Professional Services | $0-$50 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $50 |
| Psychiatric Services — Group Sessions | $50 |
| Physical Therapy & Speech-Language Pathology | $50 |
| Additional Telehealth Services (Part B) | $0-$60 |
| Opioid Treatment Program Services | $35 |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | $0-$550 |
| Laboratory Services | No charge |
| Diagnostic Radiology | $0-$225 |
| Therapeutic Radiology | 20% coinsurance |
| X-Ray Services | $50 |
| Outpatient Hospital Services | $550 |
| Hospital Observation Services | $550 per stay |
| Ambulatory Surgical Center (ASC) | $500 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $35 |
| Substance Abuse — Group Sessions | $35 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $400 |
| Air Ambulance | 20% coinsurance |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | 0%-20% coinsurance |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Diabetic Monitors | 0%-20% coinsurance |
| Dialysis Services | 20% coinsurance |
| Meal Benefit | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Fitness Benefit | No charge |
| Kidney Disease Education Services | No charge |
| Glaucoma Screening | No charge |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Vision — Eyewear Upgrades | No charge |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | $35 |
| Dental — Medicare-Covered Services | $50 |
| Dental — Preventive | See plan details |
| Dental — Oral Exams | No charge |
| Dental — X-Rays | No charge |
| Dental — Diagnostic Services | No charge |
| Dental — Prophylaxis (Cleaning) | No charge |
| Dental — Fluoride Treatment | No charge |
| Dental — Other Preventive Services | No charge |
| Vision — Eye Exams | $50 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Vision — Contact Lenses | No charge |
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Vision — Eyeglass Lenses | No charge |
| Vision — Eyeglass Frames | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Hearing — Hearing Aids (All Types) | $495-$1,695 |
Service area
- NE: 61 counties
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